Wednesday, December 11, 2013

Proof that ADHD is under-diagnosed

A common bit of hysteria that regularly screams from Australian newspapers is that ADHD is over-diagnosed and over-medicated. The media would have you believe that we are popping stimulant medications at alarming rates. Because Western Australia is a leading state in the diagnosis and treatment of ADHD, our rates of prescription for ADHD medications have often been higher than other Australian states. This caused a government department to ESTIMATE in 2002 that 4.2% of WA children were taking stimulant medication. Such a figure would have been quite in line with the international prevalence rate of ADHD, which is 4-7% for children, and 4% for adults. However, it was deemed inappropriate, and led to a parliamentary inquiry into the diagnosis and treatment of ADHD in the state. 

One outcome of that inquiry was the annual auditing of ADHD prescription rates in Western Australia. Yes - we count every stimulant pill we take.In fact, before anyone can be given a prescription for stimulant medication, they have to sign a consent from - granting the government permission to collect this data.

As a result of this careful counting we now know that the highest prescription rate of ADHD medication in Western Australian children was 1.56% (in 2004). The grossly inaccurate estimate of 4.2% assumed that 82% of medications were being prescribed for children. However, the audits have consistently shown that around 50% of ADHD medications are prescribed for children, and 50% for adults. Sadly, despite these figures being available on government websites, the media have chosen not to rectify the public misconception that ADHD is over-diagnosed and over-medicated. They have even allowed some to claim that the rates have have been reduced from 4.2%.

The Western Australian Health Department has today released the report detailing stimulant prescription rates in 2012. It informs us that 1.24% of children are prescribed stimulant medication, and 0.53% of adults. If I could perform a miracle, I would have the media inform the public that, according to the NHMRC, this is a very small portion of the 4-7% of Australian children who have the symptoms. I would also have them inform the public that the NHMRC acknowledges the prevalence rate of ADHD in adults is 4.4%, proving that ADHD is seriously under-treated in adults as well. Finally, I would have them tell the world that ADHD is a serious condition if left untreated. As the NHMRC says,"ADHD is associated with a range of adverse outcomes including educational, social, emotional and behavioural problems during childhood, and subsequent mental health, relationship, occupational, substance, abuse antisocial, and offending problems in adult life. The flow-on effects of ADHD can have a significant impact on families, schools, workplaces and the community."

Sunday, November 17, 2013

Just Add Music


All around the world parents are pulling their hair out every morning as they attempt to get their children dressed, fed and ready for school. These are some of the comments I hear:

"I send him to his room to get dressed. On the way he sees the cat, and then I've lost him."
"She can stand in the middle of her room for 10 minutes and daydream - just daydream."

"Just as we're getting into the car she remembers that she's dressed in the wrong uniform - It's Sports Day Mum !!!!"

"I manage to wave goodbye with a big sigh of relief. As he heads to the bus stop I head to the kitchen - to find his lunch has been left behind"


I know you're nodding as you read this. We've all experienced ADHD morning mayhem. One of my gorgeous teenage clients recently introduced music into her morning, and significantly reduced the collective family angst. Before I tell you her secret, let's take a closer look at the situation.

What's really happening in your child's brain as you ask him or her to brush their teeth for the third time? In previous blogs I've spoken about the Executive Function deficits that occur for people with ADHD. According to Professor Thomas Brown the Executive Functions (EFs) of the brain include the ability to organise, prioritise & activate, to monitor & self-regulate actions, to control alertness, effort & processing speed, to focus, to use working memory, to shift & sustain attention, and to control emotions. Simply put, the brain is like an orchestra, with many sections doing many things. The Executive Functions are the conductor, ensuring that all the sections work together. In the ADHD brain, the conductor is asleep! So your child is unable to remember the sequence of tasks required in order to be ready for school / work. In addition, he or she has "Time Myopia" and is unable to judge how much time is needed for, or is spent on each task. And then, when time runs out and things become urgent, your child may struggle to control their emotions. 

In order to complete a sequence of tasks, therefore, an external prompting system is required. This approach is highly recommended by Professor Russell Barkley, who constantly reminds us that ADHD requires intervention at the "point of performance". There is no point in giving your children a lecture on the importance of being ready for school on time. They know that. They also know how to get ready. What they don't know, is how to remember all the steps and complete them at the appropriate time. So what is an external prompting system and how does it work? Here are the steps:

1. Make a list (or a picture storyboard) of what needs to be done in order
2. Make the list highly visible to your child.
3. Keep your child focused on their list, as opposed to individual items.
4. Have an instant reward at the end of the list. 
5. Make time audible for your child - that's where the music comes in.

To prevent the list being forgotten, there needs to be an external audio prompt. Many of the teenagers I work with have found the 30/30 app to be perfect for this purpose. However, others are less enthralled with this technology. It's all about finding the right stimulus for your child. And for my client last week is was The Playlist Prompt. She carefully chose and compiled her morning playlist, with a song connected to each task. Then she explained to her family that she would be using it as a prompt, and asked her mum to remind her to switch it on by a certain time. The Playlist Prompt is working very well for her, especially with the following rules:

1. Check the list each time a song ends
2. Singing along is permitted, but remember that the hairbrush is not a microphone
3. Dancing is fine, as long as it happens alongside a task - e.g. the toothbrush wiggle
4. Be sensitive to your family's eardrums - use headphones if necessary.

Perhaps the Playlist Prompt is something that could work for your child?
Whatever system you use, remember that this "simple" task of getting ready in the mornings is probably one of the hardest things for your child to learn. Celebrate the successful days, and encourage him or her to improve on dodgy days. Success will not occur overnight - but it will happen if you persist.

Tuesday, October 8, 2013

Shameful Media during ADHD Awareness Month


October is Global ADHD Awareness Month, as well as Breast Cancer Awareness Month. Both have great significance for me. I was diagnosed with breast cancer in 2010, and ADHD was the focus of my PhD, so I know a fair bit about both conditions, and their treatments. I have also observed the portrayal of each condition in the media, particularly during this important month.

The West Australian newspaper, for example, must be congratulated for excellent support of breast cancer awareness. Pink front pages, numerous educational articles, and patients’ stories have all alerted the public to the seriousness of the condition, as well as the importance of early detection and treatment. Experts are regularly consulted, and Australian oncologists are portrayed as competent, caring, cutting-edge physicians – which they are indeed. By contrast, discussions in the media about ADHD focus almost exclusively on the medications used to treat it. Experts are rarely quoted, and the views of unqualified politicians are constantly given preference. Psychiatrists and paediatricians are regarded with suspicion. There is little attempt to educate the public about the seriousness of untreated ADHD.

ADHD medication featured on the front page of the West Australian last week, as well as in the Age (Age 5 Oct). However, the alarming side effects of my cancer drugs have never received that attention. This puzzles me. Among other things, the first medication I was prescribed decreased my bone density to a point where I had to stop taking it. Possible risks associated with my current medication include Deep Vein Thrombosis, Uterine Cancer, and Blindness.

WA’s new federal MP is requesting a review of government funding for an ADHD medication (West 4 Oct). This concerns me. You see, I have made the decision to continue my cancer treatment, after a balanced, informed discussion with my expert oncologist. I would therefore hate the government to stop funding it. In the same way, people with ADHD deserve the right to make informed decisions about their treatment after discussing all options with their ADHD medical expert.

The Sydney Morning Herald also joined the chorus, with a shameful heading that described children on ADHD medication as "Zombie Kids" (SMH 5 Oct). This term has created a potential situation where children with ADHD will be even more bullied in the playground. It is time for this irresponsible, uninformed, unkind reporting to stop. Which means that it is time for the College of Physicians, the College of Psychiatrists, as well as State and Federal Health Departments, to start providing factual, reasonable, and relevant information for the public when it comes to ADHD.

Thursday, August 22, 2013

Sleep Hygiene Improves Sleep Quality for Children with ADHD.






A recent study (Bessey, Coulombe & Corkum, ADHD Report, May 2013)  found that a large number of children have poor sleep hygiene. Poor sleep hygiene can be responsible for poor sleep, and poor sleep can cause ADHD symptoms to become more severe.  The study found that Improving sleep hygiene not only improved sleep in children, but also improved their daytime functioning. Further, the behavioural strategies required to implement good sleep hygiene practices are highly compatible with behavioural interventions to help parents manage ADHD in their home. Rather than viewing sleep hygiene as an additional and separate intervention, sleep hygiene may be best considered as an extension of these strategies to promote sleep at night. If your child is having difficulty sleeping, ask your doctor for help with sleep hygiene.

The study  recommends the following ABC of Sleeping:



Concept
Details & recommendations.
A
Age-appropriate
Children should go to bed and wake up at times that ensure they receive an age-appropriate amount of sleep. (See table below)
B
Bedtimes
Seat bedtimes and wake times, as well as morning & evening routines assist good sleep. Children should not go to bed later than 9pm.
C
Consistency
Bedtimes & wake-times should be consistent – even on weekends (no more than 30-60 minute difference between weeknights & weekends).
S
Schedule
In addition to bedtimes, children should have consistency through their day, including times for homework & activities
L
Location
Bedroom should be conducive to relaxation – quiet, dark & cool. Bed should only be used for sleeping (do not use bedroom for time out)..
E
No electronics in bedroom before bed
Children should not be using electronics 30-60 mins before going to bed, and they should not have electronic items in the bedroom while sleeping
E
Exercise & diet
Physical activity during the day important for good sleep, but not too close to bed time. Cool down period before bedtime. Eliminate caffeine. No big meals close to bedtime.
P
Positivity
Have a positive attitude towards sleep, and do not tackle frustrating problems close to bedtime
I
Independence falling asleep
Independence is encourage at bedtime. If children get out of bed, parents need to return them to their room
N
Needs met during day
Needs of the child should be met throughout the day – (emotional and physical).
G
Great Sleep


Age-Appropriate Sleep Times
Age
Sleep Needs
Newborn (0 to 2 months)
12 – 18 hours
Infants (3 to 11 months)
14 – 15 hours
Toddlers (1 – 3 years)
12 – 14 hours
Preschoolers (3-5 years)
11 – 13 hours
School-age children (5-10 years)
10 – 11 hours
Older children (10 – 17 years)
8.5 – 9.25 hours
Adults
7 – 9 hours

Sunday, August 18, 2013

The Focus Formula

"I have such trouble getting started on a task, and then I have trouble stopping. The only easy bit is the middle." 
The frustration expressed by my client is something that I hear often. Perhaps you can relate? - The hardest part of doing something is actually getting started. There could be several reasons for this challenge. First, as a Big-Picture, Global thinker you may find it hard to break jobs down into chunks, and establish an entry point. Secondly, if the task is difficult or boring, you could find yourself engaging in all manner of procrastination. And the list goes on. This four-point plan has proved to be very useful with many of my clients. I call it the Focus Formula.

1. Plan
If the thought of planning makes you shudder, you're not alone. Read my previous blog post on planning. For the purpose of the Focus Formula, you need to be specific about what you will be doing. Set aside some time and commit to using it for the task. Then, decide what part of the task you will work on. For example, instead of planning to "do your tax tomorrow", identify what you need to start with and when you will do it: "I will get all of my receipts out of the shoebox and sort them into categories tomorrow at 11."
2. Set Up
In order to make the assigned time productive, you need to set the task up independently from doing it. Get the shoebox of receipts out and put it on your desk. Ask yourself what else you will need to sort them. Will you need a pen and paper to make notes, for example? Have everything ready, and then walk away from the desk. Even a 10 minute break for a cup of tea will suffice. Keeping the Set Up separate prevents it from becoming a long-winded procrastination tool.
3. Sprint
ADHD brains are generally good sprinters. The thought of spending 5 hours on a tax return will fill them with dread. But they can blitz a 30 minute sprint. So make a deal with your brain - that you will give it a break in 30 minutes. Then get to work. After 30 minutes you have 2 options. You may find that you have hit the Focus Zone, and would like to keep working. If that it the case, keep at it. The Focus Formula has succeeded. However, if your brain demands the break as promised, you need to honour that. But before you walk away from the task, there is one more step:
4. Brain Dump
I have discussed the Brain Dump in some detail in a previous blog post. Essentially, it is an valuable tool to use when you are stopping partway through a task. If you walk away from incomplete work, the chances are that it will feel like starting all over again when you return. And you could hit the same brick wall. So take the time to make a note of what you need to do next. In doing so, you are creating the next entry point. When you return to the task, it will be easier to get started on your next 30 minute sprint.

The Focus Formula can be used to get started on any task that is less that tantalising. Housework, paperwork, studying and many other activities can be conquered in 30 minute sprints - until you hit the Focus Zone. 

Try it out, and let me know how you go.



Wednesday, July 3, 2013

ADHD - The Parents' Journey - Guest Blogger Annette



As parents, the backpack we carry when our journey starts with our child can place a heavy burden on the shoulders. Some days it seems light and almost feathery, though without warning, other days it becomes so weighty it feels almost unbearable.

For me the weight of a backpack coupled with the ‘briefcase of a career’ seemed at times, to be the cause of the challenges that arose with what I thought was a wonderful, happy child.

The first occasion of my ‘talks’ arose at day care when the staff were keen to advise me daily that out of all the children my child would not take a nap. “Is he upset”? “No” was the answer. “Is he disrupting the other children?” “No”. “Is he trying to keep them awake or play with them?” “No”. I struggled to see the problem. Here was a lovely happy little 18 month old boy that seemed happy to be on the mat but just sit and play or look around at others. Not disturbing just happy to day dream but not sleep. This was mirrored at home and I was perplexed with the daily ‘tut tut’ I would receive, like it was something I was teaching him to do!

Though a pattern started to emerge.

At pre school and in Grade One the same ‘talks’ were regularly presented. Not naughty, not disruptive just won’t sit and if he does he daydreams, won’t concentrate on his work, is forgetful, won’t stay on task, doesn’t seem to listen and has difficulty understand instructions. I kept asking all along the way, “Do you think he has Autism, is he ADHD.” This was always met by a negative response and in the expert opinion of these care givers and teachers it was a behavioural problem (whatever that meant?)

 By Grade Two after one to many ‘chats’ about the negatives and few positives of our lovely little boy I trotted him off to a Psychologist. After countless weekly visits and over a thousand dollars later it was declared that there was nothing wrong with the child, must be the teachers. Again I kept asking “Could he have Autism or ADHD?” “Definitely not”, was the response. His grandparents, through the magical unconditional love that they possess declared him perfect and just too clever; they also suggested it must be the teaching practices employed these days.

By now I had shifted the blame into the ‘growing heavier by the day backpack’ and declared a self prognosis of it being my fault as a full time working mother. By Grade Three a wonderful young teacher reached in and lifted a brick from the pack. “Annette do you think Hunter might have Passive ADD?” She was anxious at presenting this suggestion but the relief was immense for me.


Here was someone who had identified through research the inattentive form of the condition, not the Predominately Hyperactive/Impulsive Sub Type that most of us relate to ADHD. A stream I had never heard of. After taking her advice I also researched the subject matter and found quickly that kids with this condition do often fall under the radar during school years. Not drawing attention to themselves with hyperactivity and strong social behaviours, these quiet souls are often labeled as lazy school workers and day dreamers.

The journey continued to be a struggle as a series of testing had to be under taken to determine the condition. Visits by the Education Psychologist (who also deemed him not to be ADHD from observations), a local Doctor (reluctant to refer him to a Specialist because there was a belief he didn’t have ADHD), to the wonderful Specialist that said “I have spent three minutes with him and I think he is but let’s try fish oil and at the same time let’s get him clinically tested before we consider any medication.”

He did, he was, and he was then offered medication.

The backpack got lighter but the emotional backlash from family and friends was at times brutal. I have since realised that if you don’t live with ADHD you can’t possibly appreciate the challenges that are presented hour by hour. Not to mention the struggles experienced by those living with ADHD. I learnt to keep my mouth shut and lean on those that were supportive and encouraging at taking a proactive approach to help my son.

My son’s medication regime is designed to assist him ‘get through the school hours’. Kicking in soon after he arrives at school and wearing off at the end of the school day. Now a teenager the medication schedule is constantly being monitored and adjusted to assist with the all important after school study that is now part of our society’s educational expectations.

While the medication allows the brain connectors to ‘switch on’ and encourage focus during these blocks of hours there is a huge gap in the emotional and social needs of a fully functioning human being. Getting ready for the day, being organised enough at school and home to be able to focus on the tasks and instructions, personal hygiene and that all important social connection we all need in our lives. Building friendships and relationships and being able to read others and their emotional needs.

In our house the gap continued to grow with the body as it morphed into a teenager. While there seemed some relief in a new high school that accepted and worked with great vigour in assisting the transition from primary to high school, things were getting emotionally strained in our normally passive home environment. Then I noticed disturbing behaviours.

Fingers picked raw from stress and anxiety, scratching of the face when being confronted – it started to scream self harm and the backpack was suddenly leaden.

After a stressful morning and in a fretful state I made a call to LADS, seeking advice for the name of a Psychiatrist that could help us. After calming me down and listening to my story this amazing woman was frank “I don’t think you need a Psychiatrist, I think your son might need a coach.” Coaching was not new to me, I had undertaken Professional Business Coaching at the height of the GFC and had gone on to learn from a couple of one on one Life Coaching sessions so the idea appealed.

We were given the contact, of whom in our own words is our ‘Family Angel’. In human form she is Dr Michele Toner, ADHD Coach.

The changes to my son and our family have been dramatic. He is now able, with strategies designed for him by Michele, to have some order and management of his personal routines, plan and manage his own study paths, and is now in the midst of learning the art of conversation and forming friendships.

The outcomes and results in a short six months? He can now get ready in the morning in a home that is ‘a screeching mother free zone’, his school grades have shot from Cs and Ds to As and Bs and his confidence in making new friends and forming stronger bonds with long time acquaintances  is going from strength to strength.

I would love to say pop a pill and go to a coach and this magic cloak will appear and all will be perfect, but it isn’t true. It needs a team, made up of family and friends, a supportive school environment and an angel of a coach. You will still need to push, then run ahead and pull - but you will get them over the life line.

Perhaps our proudest moment was just a few weeks ago when at a parent teacher night we moved from teacher to teacher to be told our son was in the top ten per cent of each subject. A first! A wonderful academic achievement and great result for all his hard work, but it didn’t seem to compare to the comments promoting what a great person he was.

“Willing to try everything, someone you can trust, always putting forward a great effort even when he might not be so good at something, and more importantly if he is good at something, helping others that might not be finding it so easy. The best sum up of the night ‘This is a wonderful young man’. What more could you ask for as a parent? The backpack was empty that night!

Tuesday, July 2, 2013

The Changes that My ADHD Coach has Made to My life.



 My guest blogger is Hunter, a  wonderful 15 year boy who was diagnosed with ADHD recently. Coaching has worked well for him because he has put in a huge effort to change how he operates. He also has wonderful parents, and their story will follow soon.

Before I met Michele my life was pretty turbulent. I had difficulties getting organised at home, even getting ready for school in the morning was a struggle, my grades at school were lower than I expected them to be and I was not confident socially.

The first thing Michele and I tackled was helping me get ready in the morning by suggesting an app called 30/30. The app lets you put in things that you need to do and the time that it will take, after the timer goes off you hear a noise and you must move on to the next thing. This has really helped me in the morning, because before this I used a list on the fridge. That did not work because I had to stop what I was doing and tick whatever I had done on the list off. Since I have being using 30/30 my mornings have being calmer and way less stressful and I now leave the house much happier and more organised.   

The next thing was my school grades, when I first went to see Michele my grades were Cs and Ds, but since I have being seeing Michele my grades have risen and now my grades are As and Bs. Michele taught me strategies to help me with tests and projects.  One thing she picked up was a problem I was having with maths where I could not transition between the number questions and the word questions. She suggested I try doing all of the number questions first and then I do the word questions. I used this strategy in my maths exam and did so well the school sent my parents a letter of commendation.   

Michele has also helped me with my social life. Before I saw Michele I was nervous about asking for people’s phone numbers, but now I can because of Michele. She helped me by telling me to start conversations and find out what people like and what you have in common with them.

So Michele has helped me with getting ready in the morning, my school grades and my social life.  I could not have done any of this without Michele’s help and tips. It’s really made a huge difference to my life and managing my ADD.

Hunter, age 15.